Am I Normal?

Personality disorders may afflict 50 percent or more of people currently receiving treatment for any mental health condition. "Most patients who seek assistance are suffering from the difficulties of long-standing maladaptive attitudes and coping styles, essentially what have come to be labeled personality disorders," notes personality researcher-clinician Theodore Millon. "Dysfunctions of personality have become omnipresent" in therapy practices, he says. Millon thinks personality disorders "will outstrip all other areas of psychological and psychiatric practice in the coming decade."

Chipping Away at Disorder

Not long ago, diagnosis of a personality disorder carried a grim outlook. By and large, the only treatment available was long-term psychoanalysis. To eliminate troublesome behaviors, it was believed, you needed to change the underlying traits on which the very structure of personality had been built, day in and day out, through a person's countless interactions with the world. The few who qualified for such demanding therapy didn't necessarily benefit from it. Therapists' general attitude toward these illnesses, says psychiatrist Len Sperry of the Medical College of Wisconsin, was one of "dread and hopelessness."

Gone, along with that approach to treatment, is the Freudian view that inner conflicts arising in childhood are the sole cause. The emerging perspective acknowledges that personality, both normal and abnormal, is a complex interaction of forces inside and outside the individual—biological, psychological and social.

The antisocial personality of Bill the Shark, for example, may have originated in a genetic predisposition to aggressiveness expressed biochemically in low levels of the neurotransmitter serotonin. This inborn temperament might have been aggravated by hostile or irresponsible parenting manifest as Bill was growing up. Bill's antisocial tendencies may have reached full expression and reinforcement in social environments—casinos, strip clubs, law firms—that permitted and even encouraged combative behavior.

New treatments chip away at each element of the biopsychosocial roots of personality disorders. Drugs like selective serotonin reuptake inhibitors may act on the biochemical imbalances. Interpersonal and psychodynamic therapies take on the psychological component of the disorder, encouraging the individual to reflect on his past experiences to help release their hold on current behavior. Cognitive-behavioral and dialectical exercises (in which the person learns to challenge his own impulses) seek to shift the pattern of external rewards and punishments in favor of more controlled and constructive conduct. The new integrative paradigm, Sperry reports, has transformed clinicians' attitudes from hopelessness to optimism. From the start, Bill the Shark's antisocial personality traits presented special challenges. He "had little desire for psychological growth or moral self-improvement," Widiger notes, and his glib cockiness made genuine rapport difficult to achieve. Widiger instead took advantage of Bill's ambitious and competitive nature by challenging him to come up with ways to limit his drug use and his gambling. Using approaches borrowed from cognitive-behavioral therapy, psychologist and patient devised personal mantras that Bill would repeat to himself when faced with a temptation. "These mantras might have sounded superficial to others," Widiger acknowledges, but to Bill "they were effective, meaningful, even inspirational."

Widiger made a concerted effort not to react with judgment or disapproval when Bill regaled him with tales of his unsavory exploits. As Bill grew more comfortable, he was able to examine the roots of his behavior, coming to terms with his parents' failings and considering ways to rectify his own. Though still far from sensitive or empathetic, Bill began to recognize how hurtful his actions were to himself and to others. His essential nature was not changed by therapy, says Widiger, but he was able to smooth "the rougher edges of his personality."

Len Sperry uses an identical metaphor to describe the treatment of patients like Bill. "The clinician working with personality-disordered individuals is not a carpenter who rebuilds a structure," he notes, "but is rather like a cabinetmaker who sands down and takes the rough edges off." Ultimately, he adds, the goal is to turn a personality disorder into a personality style—to help the personality-disordered patient become a functioning, healthy human being, with quirks and idiosyncrasies intact. A person, that is, a lot like you and me.